Options Counseling AUTHORIZATION TO USE AND DISCLOSE PROTECTED HEALTH INFORMATION


 

I authorize Options Counseling & Family Services to use and disclose a copy of the specific health information described below regarding:

Name of Individual:     DOB:

Options Location:

My information may be released to or from the following Agency or Name of Individual :    
Address:  
Phone : Fax :

If the information to be disclosed contains any of the types of records or information listed below, additional laws relating to the use and disclosure of the information may apply. Information used or disclosed on this authorization may be subject to redisclosure and could no longer be protected by federal and state laws on use and disclosure. I understand and agree that this information will be disclosed if I place my initials in the applicable space next to the type of information. Initial each documentation category you are authorizing.

Drug/Alcohol diagnosis, Treatment or referral Information : HIV/AIDS Information : 
Genetic Testing : Mental Health Information:  

For the purpose of: 

 

Items not to be included:

You do not need to sign this authorization. Refusal to sign the authorization will not adversely affect your ability to receive health care services or reimbursement for services. The only circumstance when refusal to sign means you will not receive health care services is if the health care services are solely for the purpose of providing health information to someone else and the authorization is necessary to make that disclosure. 

You may revoke this authorization in writing at any time. If you revoke your authorization, the information described above may no longer be used or disclosed for the purposes described in this written authorization. The only exception is when a covered entity has taken action in reliance on the authorization or the authorization was obtained as a condition of obtaining insurance coverage. To revoke this authorization, send a written statement to:
Options Medical Records, 3500 Chad Dr. #350, Eugene OR 97408.

Clients 14 years of age and older may sign and authorize their own authorizations to release information. 
Authority :

 

 

To those receiving information under this authorization: The information disclosed to you is protected by state and federal law. You are not authorized to release it to any agency or person not listed on this form without specific written consent of the person to whom it pertains unless authorized by other laws.  

I have read this authorization and I understand it
Unless revoked, this release will expire

or upon the applicable date or event, as listed:  

Leave this empty:

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Options Counseling & Family Services https://wp.options.org
Signature Certificate
Document name: Options Counseling AUTHORIZATION TO USE AND DISCLOSE PROTECTED HEALTH INFORMATION
lock iconUnique Document ID: 2e79ddd932391686053020a5415996c7d1db12a6
Timestamp Audit
April 27, 2020 8:17 am PDTOptions Counseling AUTHORIZATION TO USE AND DISCLOSE PROTECTED HEALTH INFORMATION Uploaded by Adam Falk - adam.falk@options.org IP 50.240.25.195
April 28, 2020 11:40 am PDTAdam Falk - adam.falk@options.org added by Adam Falk - adam.falk@options.org as a CC'd Recipient Ip: 50.240.25.195
April 28, 2020 11:46 am PDTAdam Falk - adam.falk@options.org added by Adam Falk - adam.falk@options.org as a CC'd Recipient Ip: 50.240.25.195
April 28, 2020 11:53 am PDTOptions Records Department - OCFSrecords@options.org added by Adam Falk - adam.falk@options.org as a CC'd Recipient Ip: 50.240.25.195
April 28, 2020 1:19 pm PDTOptions Records Department - OCFSrecords@options.org added by Adam Falk - adam.falk@options.org as a CC'd Recipient Ip: 50.240.25.195
April 29, 2020 9:40 am PDTOptions Records Department - OCFSrecords@options.org added by Adam Falk - adam.falk@options.org as a CC'd Recipient Ip: 50.240.25.195
April 29, 2020 9:42 am PDTOptions Records Department - OCFSrecords@options.org added by Adam Falk - adam.falk@options.org as a CC'd Recipient Ip: 50.240.25.195
May 4, 2020 7:31 am PDTOptions Records Department - OCFSrecords@options.org added by Adam Falk - adam.falk@options.org as a CC'd Recipient Ip: 50.240.25.195
May 4, 2020 7:32 am PDTOptions Records Department - OCFSrecords@options.org added by Adam Falk - adam.falk@options.org as a CC'd Recipient Ip: 50.240.25.195
June 3, 2020 7:30 am PDTOptions Records Department - OCFSrecords@options.org added by Adam Falk - adam.falk@options.org as a CC'd Recipient Ip: 50.240.25.195
June 3, 2020 7:31 am PDTOptions Records Department - OCFSrecords@options.org added by Adam Falk - adam.falk@options.org as a CC'd Recipient Ip: 50.240.25.195
June 3, 2020 7:32 am PDTOptions Records Department - OCFSrecords@options.org added by Adam Falk - adam.falk@options.org as a CC'd Recipient Ip: 50.240.25.195
June 3, 2020 7:33 am PDTOptions Records Department - OCFSrecords@options.org added by Adam Falk - adam.falk@options.org as a CC'd Recipient Ip: 50.240.25.195
August 3, 2020 12:46 pm PDTOptions Records Department - OCFSrecords@options.org added by Adam Falk - adam.falk@options.org as a CC'd Recipient Ip: 50.240.25.195
August 19, 2020 10:49 am PDTOptions Records Department - OCFSrecords@options.org added by Adam Falk - adam.falk@options.org as a CC'd Recipient Ip: 50.240.25.195